Complicated by central processing that allows pain to be experienced as a cognitive function.. How we interpret pain is important and can affect patients life 0- as shown in next slide where the interplay of afferent and efferent fibres is demonstrated.
Expand on neural plasticity here – changes in chronic pain vs acute pain is important Why pain is different than hypertension eg
Medication acts on different areas of this pathway Ask the audience what medication is effective at each Here we can add in the five points to pain NSAIDs at periphery mostly Paracetamol – or acetaminophen centrally Opioids on ascending pathways interfere with sP A beta fibres affecting gating of pain in S G – T cells Descending pathways also affect T cells in SG
Neuropathic pain caused by damage to or a dysfunction of the nervous system e.g. post herpetic neuralgia, diabetic neuropathy, pain following trauma or compression is generally un-diagnosed and poorly managed Nociceptive pain is caused by noxious stimuli of pain receptors with info transferred centrally e.g inflammation or headache, it is managed by analgesics, NSAIDs or opioids
Refer Dr in Leprosy and pain experienced OR rather NOT experienced Hypnotherapy Californian paramedics etc – farmers with limbs off can switch off pain
How many patients will a pharmacist see What drugs are used in your experience How many are sub-therapeutic?
We should remind folk of the 10% rule 30mg codeine = 3mg morphine
TCA 10mg start point – emphasise mistake of starting too high in dose – side effects Nortriptyline perhaps less sedating? Explain HOW TCAs work on sodium channels – same way as anticonvulsants SSRI useful in Fibromyalgia
Specific indication in trigeminal neuralgia for carbamazepine
Might be helpful to add picture of areas likely to be affected-to allow differentiation between OA and RA-if patient just reports having arthritis Yes – affects “big “ joints – knee, hip etc Note degree of damage on flat film is often unrelated to pain experienced
Point out obvious damage and change in joint Osteophyte vs osteoblasts
Erythrocyte sedimentation rate Rheumatoid factor C reactive protein (usually diagnosis on signs and symptoms Smaller joints 0- hands as here disease-modifying anti-rheumatic drugs - discuss referral to specialist
You might want to suggest how pain diaries might be used-to identify what exacerbates pain, how it varies through the day or to show how changes in medication work-I used it to show how effective regular paracetamol is and taking medication before activities yes I will add this in here – OA for example can ease of as movement then get worse on over exercise
Pharmaceutical Care of people with Chronic Pain Deborah Paton Lead Pharmacist Pain Management NHS Fife NHS Fife